European Journal of Orthopaedic Surgery & Traumatology (2019) 29:279–284 https://doi.org/10.1007/s00590-019-02363-0

GENERAL REVIEW • UPPERLIMB - MICROSURGERY

Lateral fap: indications and techniques

Zinon T. Kokkalis1 · Efstratios Papanikos1 · George A. Mazis2 · Andreas Panagopoulos1 · Petros Konofaos3

Received: 21 December 2018 / Accepted: 2 January 2019 / Published online: 16 January 2019 © Springer-Verlag France SAS, part of Springer Nature 2019

Abstract The lateral arm fap (LAF) is a popular fap transfer, which can be applied in many procedures. It was frst described in 1982, and till then, even more clinical applications are suggested. It can be used as a free fasciocutaneous or fascial fap to cover small- to medium-sized soft tissue defects in head and neck but also in upper and lower extremity reconstruction, or as an osteocutaneous fap when vascularized bone graft is needed. We present the indications and contraindications, the advantages and disadvantages, as well as the step-by-step technique of harvesting a fasciocutaneous and an osteocutaneous fap and its complications. We conclude that the LAF is a reliable and versatile tool for reconstructive surgery, due to its anatomical characteristics and the low complication rate.

Keywords Lateral arm fap · Reconstructive surgery · Microsurgery · Defects

Introduction was also reported [5]. The latest series reported by the same group included 11 cases in which the humerus graft was The lateral arm fap (LAF) has been established as a popular used for tibial, mandible, metacarpal, radius and metatarsal fap transfer, which can be applied in many diferent recon- defects [6]. structive procedures such as resurfacing defects in the head The use as a composite tissue transfer is indicated for and neck area, as well as defects of the extremities. The various conditions, such as hand reconstruction, thumb lateral arm fap was frst described by Song et al. [1] as a reconstruction and reconstruction of combined bone and soft free septocutaneous fap that can be customized to cover soft tissue defects in the upper and lower extremity [2, 6, 7]. Such tissue or composite hand defects in diferent topographical defects can result from trauma, pseudoarthrosis, osteomyeli- areas [2]. Later, the reverse lateral fap as a local pedicle tis or tumor resection. Thumb reconstruction was carried out fap was described by Culbertson and Mutimer [3], for the by the use of osteocutaneous neurosensory lateral arm free coverage of soft tissue defects around the joint and faps in a study published by Arnež et al. [8], while fnger in the treatment of post-burn antecubital contractures [3, 4]. reconstruction with a lateral arm fascial fap including a 1.5- Katsaros et al. [5], in 1984, further defned the anatomy and cm segment of the distal humerus was reported by Chen and clinical applications of the fap, such as the use of a lateral El-Gammal [9]. Harpf and colleagues in 1998 described a arm fap in combination with a vascularised part of humerus. series of 72 lateral arm faps, 70 of which were used as fas- They reported that one patient received an osteocutaneous ciocutaneous faps [10]. The LAF as composite fap is also lateral upper arm fap with a bone segment 9 cm long. The indicated for head and neck reconstruction [11, 12]. incorporation of a vascularised portion of the triceps tendon The lateral arm fap has a consistent vascular pedicle, and it can be designed very distally as an extended lateral arm fap. Katsaros et al. [6] and Kuek and Chuan [13] were * Zinon T. Kokkalis the frst to report the clinical use of the “extended” lateral [email protected] arm fap (ELAF) in 1991, as an evolution of the LAF and 1 Department of Orthopaedics, University of Patras, School is designed by an extension of the LAF skin paddle over of Medicine, University Hospital of Patras, Papanikolaou 1, and beyond the lateral epicondyle toward the proximal fore- 26504 Rio, Patras, Greece arm. This modifcation allowed for the use of thinner and 2 Private practice, Athens, Greece more pliable skin from the proximal forearm and a longer 3 Department of Plastic Surgery, University of Tennessee pedicle length. The ELAF has been also termed as lateral Health Sciences Center, Memphis, TN, USA

Vol.:(0123456789)1 3 280 European Journal of Orthopaedic Surgery & Traumatology (2019) 29:279–284 arm/proximal forearm fap, lateral forearm fap [14], distally adjacent muscles, but run between the lateral intermuscular planned LAF, “extreme” LAF or “true” distal LAF [15]. septum and the muscles to the underlying bone allowing the lateral supracondylar ridge to be transferred without impairing the muscles. The second group of periosteal arter- Anatomy of the fap ies arises from muscular branches, which in turn originate from the PRCA; their origins are scattered among the origins The lateral arm fap is supplied by septocutaneous perfora- of the direct periosteal vessels of the frst group. After the tors of the posterior branch of the radial collateral muscular branches enter the muscles, small vessels split of (PRCA) [5, 16–18] and may include bone, muscle, tendon, and run nearly perpendicular to the surface of the underly- nerve, fascia and skin. The profunda brachii artery (PBA) ing bone at the site of muscle insertion. These two groups arises in the middle between the acromion and lateral of periosteal give of into a rich network, mainly on humeral epicondyle, and after it passes posteriorly down the the dorsal part of the humerus [16]. spiral groove, it divides into two main branches: the middle collateral artery and the radial collateral artery. The mid- dle collateral artery runs down into the medial head of the Designing the fap triceps, whereas the radial collateral artery continues along with the radial nerve. Before reaching the lateral intermus- The fap is outlined on the distal third of the lateral aspect cular septum (LIS), the radial collateral artery splits into of the arm. The axis of the skin island of the fap is centered two branches: the anterior branch of the radial collateral with a line drawn from the deltoid insertion to the lateral epi- artery (ARCA) and the posterior branch of the radial collat- condyle, which corresponds to the lateral intermuscular sep- eral artery (PRCA). The ARCA is not suitable to provide the tum (Fig. 1). The axis of the pedicle passes along the lateral basis of the fap because of its variation and the proximity of intermuscular septum, which is traced between the lateral the radial nerve. The main branch of the RCA that supplies head of the triceps muscle posteriorly and the brachialis and the lateral arm fap is the PRCA [5, 16, 17]. The PRCA trav- brachioradialis muscles on the anterior side. The fap pattern els through the lateral intermuscular septum between triceps depends upon the defect which has to be covered. The more posteriorly and brachialis and brachioradialis anteriorly. It distal the fap is made, the thinner the skin. Giving to the gives of four or fve septocutaneous perforators along the size of the defect, the dimensions of the fap can be extended intermuscular septum and ends into the epicondylar and over and beyond the lateral epicondyle as an extended lateral olecranon network. It eventually anastomoses around the arm fap (ELAF). Flap width commonly should not exceed lateral epicondyle with the interosseous recurrent artery [16, 6 cm to allow for primary skin closure of the donor defect. 19]. The length of the pedicle is 3.9 cm (range 1.5–6.0 cm), on the anterior aspect of the triceps brachii muscle, but it may reach 7–8 cm by following the vessels to the radial Harvesting technique groove [16]. Venous drainage is through one or two concomitant veins The patient is placed in the supine position and the fap can that accompany the PRCA, emptying into the profunda bra- be harvested with the on an arm table or with chii veins. Additionally, a superfcial venous system drains the arm lying on the chest and the elbow in fexion. The into the deep veins as well as into the cephalic vein, which entire arm, including the shoulder, is prepped to the axilla. courses through the anterior region of the LAF area, empty- A sterile tourniquet may be used for the procedure and must ing into the axillary vein. be placed high up in the arm. If the tourniquet interferes Two nerves should be considered in the region. The lower with proximal dissection, it must be defated at the latter lateral brachial cutaneous nerve (LBCN), arising directly part of fap harvest. Alternatively, a narrow (6–10 cm width) from the radial nerve, provides sensory innervation to the Esmark rubber tourniquet can be applied under moderate skin of the lateral upper arm; and the posterior antebra- tension. chial cutaneous nerve (PACN) innervates a more distal skin The lateral arm flap is outlined with a surgical skin area, inferior to the lateral epicondyle, that is used for the marker along with the proximal incision to expose the pedi- extended lateral arm fap [12]. cle of the fap, which lies over the lateral intermuscular sep- The lateral supracondylar ridge of the humerus, a fre- tum. Posterior fap elevation is performed frst. The posterior quently used source of bone for transfer, is vascularised by fap is elevated deep to the muscular fascia over the triceps, two groups of arteries [16]. The frst group consists of peri- which is peeled anteriorly until the septum is encountered. osteal branches that originate from the PRCA and follow a This fascia is included in the fap to preserve vascularity direct course to the bone anterior and posterior to the lateral [20]. The fascia is sutured with two to three stitches to the intermuscular septum. These vessels do not penetrate the skin to avoid a separation of skin and fat layer. As the fap

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Fig. 1 Raising the fap. BA , PBA profunda brachii ECRL extensor carpi radialis longus, RN radial nerve, PACN poste- artery, RCA ​radial collateral artery, PRCA​ posterior branch of radial rior antebrachial cutaneous nerve, LIS Lateral intermuscular septum, collateral artery, LLBCN lower lateral brachial cutaneous nerve, MRCA ​middle branch of radial collateral artery ARCA ​anterior branch of radial collateral artery, BR brachioradialis, is elevated toward the septum, small muscular perforators (ARCA) is ligated distally from the bifurcation of the RCA, are encountered and have to be coagulated or ligated. The and further dissection of the RCA is accomplished proxi- pedicle and septum are identifed together and exposed from mally up to its origin to the profunda brachii artery. distal to proximal. Following hemostasis, the donor site is closed primar- Then the anterior aspect of the fap is elevated. The same ily if the fap width is less than 5–6 cm. Otherwise, a split dissection is performed exposing the brachialis and brachio- thickness skin graft is used, after reduction in the defect size radialis muscles. The fascia here is slightly more attached to by closing the proximal and distal ends primarily. In some the muscles. The fap can be elevated from distal to proxi- conditions, a Z-plasty can be used for primary skin closure mal. The artery and vein at the distal aspect are ligated and to avoid a straight scar on the lateral side of the elbow. divided. Staying deep to these vessels, the intermuscular septum is released to the level of humeral periosteum and the septum is now raised, with periosteum, from the humerus proximally to the level of deltoid insertion. As the dissection Osteocutaneous lateral arm fap proceeds more proximally, the distance between the vessels and the humerus increases, and the dissection is easier. The If a vascularised bone graft is required, an osteocutaneous radial nerve comes into view proximally (Fig. 1). lateral arm fap can be raised. The approach is similar to the Once adequate pedicle length is gained, the PRCA and standard fap description. It is important to preserve the 3–4 venae comitantes are divided and used as the pedicle of the small periosteal branches from the PRCA in the intermus- lateral arm fap. If the neurosensory fap is to be harvested, cular septum which supplies the distal lateral humerus. For the lower lateral brachial cutaneous nerve (LLBCN), which the harvest of the lateral supracondylar ridge of the humerus, enters the skin fap proximally and superfcial to the triceps the lateral intermuscular septum should be left attached to fascia, is identifed and divided proximally. the humerus to avoid accidental injury to the septocutaneous To gain more pedicle length and a wider caliber of ves- branches within [16, 21, 22]. The PRCA has to be centered sels, the incision can be elongated by extending it proxi- in the middle of the bone graft, and it is essential to preserve mally. The triceps and brachialis muscles are retracted to the periosteum attached to the bone. A muscular portion of identify the proximal pedicle and to ligate branches. The brachioradialis and extensor carpi radialis longus anteriorly RCA and its venae comitantes are cautiously separated from and triceps brachii posteriorly can be included to protect the radial nerve, while care should be taken not to retract the periosteal branches. A segment of bone between 3 and the nerve. The anterior branch of the radial collateral artery 6 cm above the lateral epicondyle can be harvested with a

1 3 282 European Journal of Orthopaedic Surgery & Traumatology (2019) 29:279–284 consistent blood supply from the periosteal branches of the defects, considerable BMI of the patient which results in a PRCA [16, 22]. bulky fap and the rather obvious scar of the donor site.

Advantages/disadvantages Indications/contraindications The lateral arm fap has several advantages over other faps. The lateral arm fap is a versatile transfer for various recon- It has a consistent anatomy and blood supply for local and structive purposes, including composite defects which free tissue transfer [5, 10, 12]. Its pedicle is a non-dominant require bone, tendon or sensory nerve reconstruction. As end artery, constant and easy to dissect. Additionally, the other free faps have been described and widely used during unique vascular plexus over the lateral elbow region allows the last decades [23–25], it can be used as a free fasciocuta- great variability in design. The fap is relatively thin, poten- neous fap not only in head and neck but also in upper and tially sensate, providing thin skin essential for hand recon- lower extremity reconstruction. It can be raised as a fascial struction [4, 5, 14, 15]. It is a versatile fap and it can be used fap, including the overlying fat if bulk if required. Com- as a composite fap, e.g., tenocutaneous, osteocutaneous monly, this fap is applied for small to middle-sized hand and fasciocutaneous fap which can provide the feasibility and wrist defects, as a free fasciocutaneous or fascial fap for to reconstruct three-dimensional defects in a single-stage dorsal or as free fascial fap for palmar defects. Moreover, it approach [2, 6, 7]. The donor site can be closed primarily can be used for reconstruction of the nose, the mandible and with minimal morbidity. The resultant scar can be easily closure of traumatic metatarsal defects. covered by a T-shirt, in contrast to the radial forearm fap. The LAF can be used as a local fap to cover defects over The disadvantages of the lateral arm fap include pares- the shoulder and elbow. It can be islanded proximally on the thesia or anesthesia of the posterolateral side of the arm and posterior radial collateral artery for defects of the upper arm forearm, due to transection of the LBCN and/or the PACN. reaching to the coracoid area or the axilla, or distally as a However, this area of hyposensibility is signifcantly reduced reverse fap, based on the interosseous recurrent artery, for after 6 months because of ingrowth of the neighboring cuta- reconstruction of soft tissue defects (Fig. 2) or burn contrac- neous nerves [26, 27]. In obese patients, the bulkiness of tures around the elbow region [3, 4]. the fap may lead to patient dissatisfaction and secondary The use of lateral arm fap may be contraindicated in defattening procedures. Also, hair growth in the skin terri- cases previous trauma or surgical procedures of the donor tory of the fap in some male patients can sometimes be an area, due to the uncertain perforator dependent vascularity inconvenience, especially when the fap is transferred to the of the fap. In addition, the LAF is less suitable for defects head and neck region. wider than 5–6 cm or otherwise skin grafting may be needed, followed by a secondary procedure for scar correction. Fur- thermore, in case of a patient with serious comorbidities Complications or poor general health status, the use of other less demand- ing and shorter reconstructive procedures may be indicated. The problems with the LAF/ELAF transfer relate to donor Other relative contraindications are mainly esthetic rea- site morbidity. Lateral epicondylar pain and hypersensitive sons like hair transfer in cases of face, neck or palmar hand scar, present in 19.4% and 17% of Graham et al.’s series

Fig. 2 52-year-old patient developed an infection of distal humerus the plates were exposed (a), and the soft tissue defect was covered after an osteosynthesis with two plates due to distal humerus frac- with the reverse lateral forearm fap. b The donor area was primarily ture. A reverse lateral forearm fap distally based on the interosseous closed (one half), and the other half was covered with split thickness recurrent artery was performed. After thorough surgical debridement, skin graft

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Table 1 Summary of lateral arm fap series No. of patients Follow-up Complications Conclusion

Graham et al. [27] 123 3 years 27% unsatisfactory appearance (twice as Lateral arm fap should be limited to males likely in female patients) and cases in which the resulting donor 19% elbow pain site can be closed primarily 78% hair formation Harpf et al. [10] 72 6 months–10 years 15.3% arterial or venous thrombosis Outcome without nerve coaptation was more satisfactory than with the nerve coaptation Akinci et al. [7] 74 3.6 years 7% lost due to venous thrombosis Versatile in covering moderate-sized 21% uneven color match and cold intoler- defects of the upper extremity with little ance morbidity and with acceptable cosmesis 12% required thinning procedures 9% hair growth Ulusal et al. [2] 118 17 ± 6.2 months Three losses (one arterial occlusion and LAF and its variants can be reliably used two deep wound infections) and provide stable skin coverage with 84.5% required secondary procedure to satisfactory cosmetic outcomes in hand improve functional outcome defects. However, overall functional out- 16.1% required debulking procedures come is invariably afected by the initial severity of the injury

[27], are associated with patient dissatisfaction. The use of which does not compromise the vascular supply of the a split thickness skin graft to cover the donor site is likely to hand as it does not sacrifce a major artery. Also the dis- result in unsatisfactory appearance. Lateral epicondylar pain section is relatively easy and allows two surgical teams is most often associated with primary closure of the donor to work simultaneously which reduces the total surgical site. This may relate to tight wound closure or to the inclu- time. Additionally especially for upper extremity recon- sion of the epicondylar periosteum into the fap [26]. Some structions, it provides good surface for tendon gliding and restriction in elbow motion may be also resulted. also a vascularized tendon can be harvested as well as a Fascia closure and hematoma formation of the donor site segment of bone. This allows a single-stage reconstruction have to be avoided as they can lead to elevated intracompart- of composite defects and early mobilization which is a key mental pressures and subsequent compartment syndrome. factor for optimal results. Moreover, secondary surgical Another serious complication, in case of an osteocutaneous procedures such as debulking and tenolysis can be easily lateral arm fap, is the iatrogenic fracture of the humerus performed. The donor site can be closed directly to a width which has to be treated accordingly, in order to avoid mal- of up to 8 cm and is in areas that can be concealed with union, nonunion or ipsilateral elbow stifness. low morbidity and acceptable esthetic results. Despite all Additionally, while lateral forearm numbness is a com- the advantages, an important drawback is that this fap has mon postoperative complaint, the formation of a painful a relative short pedicle length compared to others, such neuroma of the PACN may have to be treated in another as the radial forearm and the anterolateral thigh faps [7, surgery with neuroma resection and coverage of the stump 17, 28]. under healthy soft tissues. A thorough discussion with the There are several series presenting cases treated with LAF patient explaining the details of this procedure in terms of and its variations. Table 1 summarizes the largest series. potential donor and recipient site morbidity will set realistic Graham et al. [27] in 1992 performed 123 LAF over a expectations and diminish the risk of dissatisfaction of the 7-year period with 89% of them reviewed over a 3-year patient following this complex surgery [27]. period and reported complications and morbidity of the donor and recipient sites, such as 27% unsatisfactory appearance of the donor site which was twice as likely to be Discussion reported in female patients and in cases that demanded split thickness skin graft for closure, elbow pain in 19% and hair In the recent years, due to its advantages over the alter- formation in 78% of patients. native faps, it has been widely accepted as a microsur- Harpf et al. [10] in 1998 transferred 72 free LAF in 68 gical workhorse for soft tissue reconstruction of small patients and studied the efect of nerve coaptation versus to medium defects of the extremities and head and neck no nerve coaptation measuring the objective and subjec- region when a free fap may be necessary. LAF/ELAF has tive grades of sensibility at the recipient site. The follow- a constant vascular anatomy (terminal branch of the PBA) up was 6 months to 10 years, and surprisingly, the outcome

1 3 284 European Journal of Orthopaedic Surgery & Traumatology (2019) 29:279–284 without nerve coaptation was more satisfactory than with 8. Arnež ZM, Kersnič M, Smith RW, Godina M (1991) Free lateral the nerve coaptation. arm osteocutaneous neurosensory fap for thumb reconstruction. J Hand Surg Am 16:395–399 Akinci et al. [7] conducted a series of 74 LAF on 72 9. Chen H, El-Gammal TA (1997) The lateral arm fascial free fap for patients and reported 93.2% success rate with 7% lost due resurfacing of the hand and fngers. Plast Reconstr Surg 99:454–459 to venous thrombosis. A higher failure rate was encoun- 10. Harpf C, Papp C, Ninković M, Anderl H, Hussl H (1998) The lateral tered with the cases of high-voltage electric burn. arm fap: review of 72 cases and technical refnements. J Reconstr Microsurg 14:39–48 Some of the larger series of LFA is from Ulusal et al. 11. Ninković M, Harpf C, Gunkel A, Schwabegger A, Thumfart [2] in 2007 described a series of 118 traumatic hand W, Anderl H (1999) One-stage reconstruction of defects in the defects treated with the use of LAF from 1990 until 2004. hypopharyngeal region with free faps. Scand J Plast Reconstr Surg The mean follow-up period was 17 ± 6.2 months, and Hand Surg 33:31–39 12. Ninkovic M, Disa JJ (2009) Flaps and reconstructive surgery. In: the overall success rate was 97.5%. Only 16.1% required Wei FC, Mardini S (eds) Flaps and reconstructive surgeons. pp debulking and poor functional results were described for 305–319 the recovery of the hand contractures and the reconstruc- 13. Kuek LBK, Chuan TL (1991) The extended lateral arm fap: a new tion of the extensor tendons in the composite fap group. modifcation. J Reconstr Microsurg 7:167–173 14. Lanzetta M, Bernier M, Chollet A, St-Laurent JY (1997) The lateral In conclusion, LAF and its variations could ofer us a forearm fap: an anatomic study. Plast Reconstr Surg 99:460–464 reliable tool for treating defects of diferent types, due to 15. Hage JJ, Woerdeman LAE, Smeulders MJC (2005) The truly distal its anatomical advantages as well as the low complication lateral arm fap: rationale and risk factors of a microsurgical work- rate after its use. So we propose the use of LAF for small- horse in 30 patients. Ann Plast Surg 54:153–159 16. Hennerbichler A, Etzer C, Gruber S, Brenner E, Papp C, Gaber or medium-sized defects in the upper extremity as well as O (2003) Lateral arm fap: analysis of its anatomy and modifca- head and neck, after a thorough discussion with the patient tion using a vascularized fragment of the distal humerus. Clin Anat and the use of this method by a skilled and experienced 16:204–214 surgeon with thorough knowledge of the anatomy of the 17. Yousif NJ, Warren R, Matloub HS, Sanger JR (1990) The lateral arm fascial free fap: its anatomy and use in reconstruction. Plast upper extremity. Reconstr Surg 86:1138–1145 18. Karamürsel S, Baǧdatlý D, Markal N, Demir Z, Çelebioǧlu S (2005) Compliance with ethical standards Versatility of the lateral arm free fap in various anatomic defect reconstructions. J Reconstr Microsurg 21:107–112 Conflict of interest All authors declare that they have no confict of 19. Rivet D, Bufet M, Martin D, Waterhouse N, Kleiman L, Delonca interest. DBJ (1987) The lateral arm fap: an anatomic study. J Reconstr Microsurg 3:121–132 Ethical approval All procedures performed in studies involving human 20. Scheker LR, Harold HE, Hanel DP (1987) Lateral arm composite tis- participants were in accordance with the ethical standards of the insti- sue transfer to ipsilateral hand defects. J Hand Surg Am 12:665–672 tutional and/or national research committee and with the 1964 Helsinki 21. Teoh LC, Khoo DB, Lim BH, Yong FC (1995) Osteocutaneous Declaration and its later amendments or comparable ethical standards. lateral arm fap in hand reconstruction. 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